An anti-smoking campaign in China, the biggest consumer of tobacco products.

As the tobacco industry continues to innovate to preserve its market appeal, the health sector needs to become even more creative – advocating for new regulations to reduce tobacco’s appeal and increase product costs. Among those: limiting nicotine content, banning filter tips, and joining WHO’s new “3×35 initiative” to raise the price of tobacco products by 50%. 

We’re on the brink. For much of the last 20 years, smoking has been in decline worldwide, saving millions of lives, but we are at an inflection point. Trends point to a flattening in the decline of cigarette sales, and Big Tobacco is responding to two decades of public health progress with insidious innovation. If public health practitioners don’t out-innovate the industry now, we’ll be setting ourselves up to lose.

It is a monumental public health achievement that global tobacco use dropped by a third in the last 20 years. More than 5.5 billion people are now covered by some measure that discourages tobacco use, such as advertising bans, higher taxes and quit programs. For the first time, an entire region, Latin America, has smoke-free laws in place.

But we cannot expect the hard-won anti-tobacco laws of today – those that have created smoke-free spaces, banned advertisements around schools and removed flavors from cigarettes which have saved millions of lives – to protect us from the industry’s plans for tomorrow.

Despite its seemingly anti-cigarette rhetoric, the industry is not slowing down on its core product – monetizing addiction. There are too many signals to ignore: Philip Morris International shipped more cigarettes in the first quarter of 2025 than during the same period last year. British American Tobacco just launched a new cigarette brand in Korea. Japan Tobacco International is building a new factory in Morocco.

Industry is innovating around anti-smoking regulations 

Tobacco industry innovation includes a barrage of new tobacco products.

The industry is also innovating its way around current anti-smoking regulations, releasing a barrage of new products like e-cigarettes (vapes), heated tobacco products and nicotine pouches. When laws threaten to restrict or ban these addictive products, tobacco companies try to influence politicians to advocate for them, often as the “lesser evil”. 

These products are increasingly being targeted at the next generation. The industry has lobbied for heated tobacco products to be exempt from the UK’s new Tobacco and Vapes Bill so they can continue to be sold to people who would no longer be able to buy cigarettes. It also wants to continue promoting these products in a wide range of retail outlets, which has included items at children’s eye-level, near sweets in filling stations. 

Meanwhile, there are reports from across the UK of nicotine pouch giveaways at railway stations and tobacco companies sponsoring music events like the Reading and Leeds Festival, where many teens go to celebrate the end of exams.

If nothing is done to counter the industry’s strategies, not only will declines in smoking be reversed, but new epidemics will arise. Indeed, an e-cigarette epidemic already has, with vapes being used more by teens than adults in many countries. We’re risking a future where the next generation won’t have the same protections.

Out-innovating big tobacco 

But tobacco companies aren’t the only ones innovating. New ideas are emerging that can move the needle in the right direction, for good. 

We can require that cigarettes have less nicotine, so that fewer people get hooked for life. We can use technology to blur out tobacco company logos and branding in Formula 1 races, as in France, and address imagery on streaming platforms, like in India. 

We can institute “polluter pays” penalties where tobacco companies compensate for the environmental damage their products cause, like in Spain. We could ban filters to remove a product design element that makes it easier to smoke and eliminate the most littered single-use plastic in the world. We can prohibit the youngest generations from ever being allowed to buy tobacco.

These solutions can be agile and deployed at the national, provincial or city level. The generational end game law, which makes it illegal to sell tobacco to anyone born after a certain date, is being pioneered at the city level in Brookline, Massachusetts, in the United States. A similar law is set to go into effect in the UK soon.

To prevent a backslide into the era of smoke-filled rooms and Joe the Camel, these solutions need to be accelerated and supported in every country.

So there couldn’t have been a better time for the tobacco control community to gather than at the recent World Tobacco Conference in Dublin, Ireland. 

Experts and advocates from around the world convened in a country that itself is wrestling with stalled declines in tobacco use and a rise in youth e-cigarette use. While Ireland aimed to reduce tobacco use to less than 5% by 2025, recent data shows it hovering at 17%. Worryingly, a 2022 survey revealed that two in every five girls and a quarter of boys aged 15-17 had used an e-cigarette.

Convening in Dublin provided an opportunity to double down and renew the push for what we know works: advertising bans, smoke-free laws and – the gold standard – higher tobacco taxes. 

Raising real prices

Following that major meeting, the World Health Organization (WHO) has now launched a big new initiative urging countries to raise real prices on tobacco, alcohol, and sugary drinks by at least 50% by 2035 through health taxes. The “3 by 35” Initiative is based on studies showing that a one-time 50% price increase in these products could prevent 50 million premature deaths over the next 50 years. 

This period between Dublin and the upcoming UN High Level Meeting on Noncommunicable Diseases in September is a time to mobilize action behind these creative new solutions that can counter Big Tobacco well into the future.

The tobacco industry is playing the long game, and we need to, too. No public health win is permanent. If politicians and the public aren’t vigilant, Big Tobacco will continue trying to dismantle laws that protect health, while finding ways to bypass others. The next era of tobacco control requires innovative solutions – they will make all the difference. 

Dr Mary-Ann Etiebet is the President and CEO of Vital Strategies where she leads a team of over 400 people in over 80 countries working to advance long-term solutions for the growing burden of noncommunicable disease and injury.

Image Credits: Johannes Zielcke, Filter.

Delhi traffic officer Ashok Kumar explains the new rules on 1 July.

NEW DELHI – When drivers entered fuel stations on 1 July, they found bright new warning signs and traffic police positioned at the fuel pumps. Old vehicles would be identified by special, new cameras and denied fuel. Drivers  also risked having their vehicles seized for “liquidation.” 

The day marked the beginning of a widespread campaign by central government’s Commission for Air Quality Management (CAQM) in the Delhi region to reduce air pollution.  

Any gasoline-powered vehicle older than 10 years, or a diesel vehicle older than 15 years, was supposed to face action – and at least 80 such vehicles were seized initially.

Although some  6.1 million over-age vehicles are registered, the actual number on the roads is far lower, and some estimate it to be around 400,000. 

However, enforcement quickly fizzled out after the Delhi state government sought a pause following protests on social media. Many of these went viral and were also reported widely in the media. 

Enforcement aided by advanced new cameras

To identify these vehicles at the pumps and on the road, CAQM installed hundreds of advanced cameras with automated number plate recognition (ANPR) linked to a database. 

The ban on such older vehicles circulating in Delhi was first introduced in 2015, but after two days of protests over the enforcement, the Delhi government pressured CAQM to put the operation on hold. 

Chief Minister of Delhi Rekha Gupta tweeted that the decision should be suspended as it was adversely affecting the daily lives and livelihoods of millions of families. She called for a practical, equitable, and phased solution.

Delhi’s environment minister, Manjinder Singh Sirsa, cited several “technological gaps” in the ANPR system in a letter to CAQM posted on X on Thursday. These include that it lacks robustness, there are crucial glitches in the camera placement, sensors aren’t working, and the system is not fully integrated with databases of states neighbouring Delhi. He called for a “holistic approach and implementation” in Delhi and its neighbouring regions. 

However, a source told Health Policy Watch that ANPR was able to identify up to 6,000 overage vehicles per day during tests, and described it as a “foolproof” method. Tests conducted since last December showed that the system has worked well. 

Ironically, a day before the enforcement drive began, Gupta of Prime Minister Narendra Modi’s BJP Party said that the Delhi state government would follow orders of the courts and the CAQM.

Despite repeated inquiries from Health Policy Watch, CAQM did not provide any details on the future of the campaign in Delhi. However, it made it clear in a press release related to curbing pollution in neighbouring Haryana state, that it intends to continue to advocate for the liquidation of the ‘end-of-life’ (EoL) vehicles plan and ANPR cameras. 

The initial campaign in Delhi was supposed to be part of a regional initiative by Indian authorities that aimed to get an additional 4.5 million EoL vehicles off the road starting in two phases in November,  then April 2026. The rollout of ANPR cameras in other states and cities had also begun. 

However, as long as the Delhi State Government opposes enforcement, the agency will find it difficult to continue to clean up Delhi.  

Weak political appetite to tackle air pollution

The call for a pause signals the weak political appetite of the five-month-old Delhi government to take hard decisions to improve air quality in what has frequently been ranked as the world’s most polluted capital over the past decade. 

Even before Sirsa’s letter to CAQM last week, there was a perceptible shift in the party’s tone. In March, Sirsa promised an early crackdown on polluting vehicles that are a major contributor to Delhi’s annual air pollution, particularly in winter:

Older vehicles emit high levels of polluting nitrogen oxide (NOx), sulphur dioxide (SO2) and contribute to the microscopic pollutant, PM2.5. In 2024, PM2.5 levels reached peaks of 732 micrograms per m3 – about 73 times higher than the World Health Organization’s (WHO) 24-hour guideline level. 

But on 2 July after the protests, Sirsa blamed the previous Aam Admi Party (AAP) government for not enforcing the ban earlier:

The protests included many influential voices across the political spectrum. But most ignore health impacts and the fact that the older cars have outdated fuel standards, which means that they are inevitably more polluting, regardless of how well they may have been maintained. 

Health impact of vehicular pollution 

Drivers and passengers in heavy traffic with many polluting vehicles are typically exposed to excessively high levels of oxides of Nitrogen (NOx) from gasoline vehicles, as well as fine particulates, PM2.5 from diesel. 

Even short-term exposure to high levels of those pollutants prompts immediate, physiological responses, including headaches, irritation in the eyes, nose and throat, and difficulties in breathing. 

Chronic, long-term exposure to traffic pollution can have far more severe health effects, worsening asthma and other lung disorders, cardiovascular problems and high blood pressure, leading to premature death. 

Air pollution has also been identified in a new report as being a more significant cause of lung cancer in ‘never smokers’ than previously believed, according to a new study published in Nature. Patients from regions of the world with high levels of air pollution were more likely to have genomic mutations linked to cancer.

In Delhi alone, 7.8 years life years are estimated to be lost from air pollution while the average for India is 3.6 years. 

WHO’s South East Asia region, which extends east from Pakistan to Bangladesh, continues to have the highest overall burden of disease from air pollution, and India is one of the worst-affected countries. A little over two million Indians a year die from air pollution, with the worst effects concentrated in Delhi and other major cities. 

Air pollution is also linked to obesity, diabetes, metabolic dysfunction and genomic damage, points out Dr Sanjeev Bagai, a prominent paediatrician in Delhi. 

“Vehicular pollution is the lesser-mentioned culprit causing serious human harm,” he said in an interview with Health Policy Watch.

Vehicles are a big chunk of Delhi’s air pollution

In the Delhi region, vehicles contribute significantly to the air pollution crisis. According to officials, vehicles emit 78% of the nitrogen oxide (NOx), 41% of sulphur dioxide (SO2), and at least 28% of PM 2.5 particulate matter pollution –  although some estimates put it at 40% and as much as 50% in winter. Much of the NOx also converts to PM 2.5, which is so fine that it can settle deep into the lungs and other organs, causing damage. 

Neither the science nor the policy to get older vehicles off the road are new.  A ban on EoL vehicles has been in force since 2015, when it was first ordered by the nation’s top environmental court, the National Green Tribunal (NGT). The ban was upheld in 2018 by the Supreme Court and in 2024, a powerful panel headed by the country’s top bureaucrat, then Cabinet Secretary Rajiv Gauba, called out the “very slow progress” on implementing the ban. 

Science vs #DelhiFuelBan protests

Many of those criticising the crackdown claim that 10 or 15-year-old vehicles can remain in good condition. For instance, one social media user praised his father’s 16-year-old Mercedes as a so-called “zero pollution” vehicle.

The facts, however, don’t bear that out. Vehicles with the latest fuel standard –  Bharat Stage 6 (BS 6), equivalent to Euro 6 – emit far less pollution than earlier standards, according to a study by the International Council on Clean Transportation (ICCT). 

In its 2024 report, the ICCT said that so far, India’s “leap” from BS 4 to BS  was contributing to “significant reductions in tailpipe emissions.” Even 5- to 10-year-old vehicles with a BS 4 standard are approximately five or six times more polluting, while those that are 10 years or older, with BS 3 and BS 2 standards, can be 10 and 11 times more polluting, ICCT said.

But the claim that well maintained older vehicles are “clean” are being widely promoted, including by this influencer with over 15 million YouTube followers:

Protests across political spectrum

Criticism of the ban has come across most of the political spectrum. An opposition Member of Parliament, Saket Gokhale of the Trinamool Congress, called the ban “ridiculous” and a “major financial hit to the middle class”, affecting six million owners. He has written to the federal transport minister asking for the policy to be withdrawn:

A columnist appealed to Prime Minister Modi, who follows her on X, to allow old vehicles that comply with emission norms. She cites an automobile manufacturers group, which claims that a large number of these vehicles can meet stringent standards. 

Most air quality advocates are silent

On the other hand, the usually vocal air quality advocates were largely silent. The authorities also did not defend the ban once the protests began increasing. 

Approaches by Health Policy Watch to several organisations yielded no response. Amongst the few exceptions were Karthik Ganesan and Arpan Patra of the Council on Energy, Environment and Water (CEEW). 

In an article on Thursday in the Indian Express, they welcomed the measures as being a good, first step shortly before the campaign was suspended. 

“The restriction on the fuelling of end-of-life vehicles in Delhi firmly communicates the government’s intent to curtail pollution… This ban must cascade into the following logical next steps to truly clean up transportation emissions,” wrote Ganesan and Patra.

Until now, the government had largely relied on frequent, mandatory pollution checks on vehicles that pulled into service stations, but these use old technologies that only check for very high levels of smoke particles and carbon monoxide. They don’t capture data on fine particulate matter, nitrogen oxides and sulphates, which are the pollutants most harmful to human health. 

As for more sophisticated testing, there are only two vehicle fitness centres in the entire city of more than 22 million people capable of this.

Meanwhile, studies by the ICCT and others have demonstrated that filtering vehicles by their age rather than rudimentary and outdated emissions tests, is a more reliable means of getting polluting vehicles off the road. 

Cameras installed at Delhi service stations can identify older vehicles by their registration plates. But their use now hangs in the balance after the government suspended implementation of the ban on older vehicles.

Will the new Delhi government ever step up? 

Experts say that enforcing the ban is just one step in reducing Delhi’s air pollution at its source. Public transport is patchy and buses don’t reach many neighbourhoods. 

About 31% of urban neighbourhoods in Delhi fall outside a 500-meter radius of a public bus stop, a threshold recognised as the standard for walkable access under India’s Transit-Oriented Development (TOD) policy, according to a recent study.

If the government does eventually enforce the ban on old vehicles using its updated technology, it will also be expected to enforce other court orders and pollution curbs  like the ban on fire crackers and steps against waste burning. 

If it doesn’t, it will need to contend with the optics. As Ashwini Tewari, the chief of India’s largest bank, State Bank of India, pointed out recently, foreigners want to avoid the Delhi region, including the booming city of Gurgaon on its southern border, where major multinationals like Google, Microsoft, IBM and Deloitte have large offices. 

The quality of the Delhi government’s air pollution mitigation strategies thus has major economic implications at the national as well as local level. 

The record for this new BJP government, which came into power in February, remains very mixed. While it is continuing and extending policies such as more EV buses, it is also is facing criticism for a plan to install so-called ‘modern air purifiers’ in the park of an elite neighbourhood despite a failed earlier experiment with outdoor smog towers. 

The new plan is to install 150 such ‘air purifiers’ over 85 acres. But with Delhi is spread over 366,000 acres, any such initiative will be ineffective, as experience and studies have shown. 

Cutting pollution at source is always a better option, as air quality researchers point out. For now, a series of pollution maps of Paris, showing how a curb on vehicles improved air quality, has gone viral in India. 

Data maps show the effect of vehicle curbs on lower air pollution in Paris

 

Image Credits: Asian News International, Chetan Bhattacharji, University of Chicago, Airparif.

North Darfur capital of El-Fasher from above.

Mass atrocities, rape, famine, sexual and ethnically targeted violence have plagued Sudan’s civil war since it erupted two years ago. With peace nowhere in sight, a new report released by Médecins Sans Frontières (MSF) recounts in devastating detail: nothing has changed. 

Based on interviews with over 80 civilians, MSF data and direct observations from its medical teams, the report documents the violence and humanitarian catastrophe unfolding in El Fasher, the capital of North Darfur, where the Rapid Support Forces (RSF) have encircled hundreds of thousands of people while laying the city under siege.

Mass killings and starvation are underway, MSF found. Food, water, and humanitarian aid are blockaded. Food shops and markets, water towers and pumps, hospitals and healthcare facilities are under constant attack.

The Sudan Doctors Network reports 239 children have died from malnutrition in El Fasher since January as nearly half of Sudan’s remaining population facing acute food insecurity turn to boiling weeds and wild plants to survive.

Gunfire, airstrikes and artillery are already raining down on the city as the warring factions compete for control. But MSF warned further escalation is still possible: an all-out RSF assault on the capital.

“In light of the ethnically motivated mass atrocities committed on the Masalit in West Darfur back in June 2023, and of the massacres perpetrated in Zamzam camp in North Darfur, we fear such a scenario will be repeated in El Fasher,” said Mathilde Simon, MSF’s humanitarian affairs advisor. “This onslaught of violence must stop.”

‘Clean El Fasher’ 

An MSF nurse attends to a patient amid the violence in North Darfur, April 2025. / MSF

Ethnically targeted attacks by the RSF on non-Arab communities, particularly the Zaghawa, are “protracting the ethnic violence that has ravaged Darfur for over twenty years,” MSF said.

“RSF and their affiliates repeatedly shelled neighbourhoods and gathering places of civilians known to be from non-Arab communities, ground attacks were systematically carried out, involving the looting of belongings, killing of civilians and razing of houses and infrastructure,” the report found. “Sexual violence was widely perpetrated, and numerous abductions were reported.”

The RSF is a descendant of the Janjaweed militia that led the Darfur genocide, targeting non-Arabs across the region and killing an estimated 300,000 people from 2003 to 2005. 

Mohamed Hamdan Dagalo, the general known as Hemedti who heads the RSF, led Janjaweed paramilitaries that burned villages, killed civilians and raped ethnic Africans across his native Darfur during the genocide. These crimes led to the indictment of his then-commander and deposed Sudanese president, Omar al-Bashir, by the International Criminal Court for war crimes and genocide.

With the shadow of a repeat of history looming over the province, MSF reported several witnesses testified they overheard RSF soldiers airing plans to “clean El Fasher,” raising the spectre of a second genocide – or that it is already underway.

“Only God knows what will happen in El Fasher,” one man, 41, told doctors. “But if the RSF take El Fasher, they will carry out ethnic cleansing and genocide, like what happened in El Geneina.”

El Geneina, the capital of West Darfur, was systematically cleared of its Massalit population by RSF and allied militias through killing and forced displacement in 2023. The total number dead in the violence is unknown. A UN expert panel estimated between 10,000 and 15,000 people were killed, while Sudanese Red Crescent staff identified 2,000 bodies on the capital’s streets before they stopped counting.

As MSF urges the warring parties to spare civilians and grant access for humanitarian organisations to provide critical aid to people in need, RSF forces took control of the tri-border area with Libya and Egypt in June, gaining control over critical supply routes and threatening to open new fronts in the civil war. 

“As patients and communities tell their stories to our teams and asked us to speak out, while their suffering is hardly on the international agenda, we felt compelled to document these patterns of relentless violence that have been crushing countless lives in general indifference and inaction over the past year,” Simon said.

Despite a UN arms embargo, weapons continue flowing to both sides through neighbouring countries, several of which, including Libya, Chad and the Central African Republic, are major arms trafficking hubs, UN experts say. 

While Egypt and Saudi Arabia back government forces, the UAE, Libya and Russian-linked Wagner Group support the RSF. The UAE has invested over $6 billion in Sudan since 2018, viewing the resource-rich nation as key to expanding its regional influence.

Around 40,000 people have been killed and 13 million displaced since the civil war began in April 2023, according to the latest UN estimates.

Peace, at this juncture, is nowhere in sight.

Nowhere to hide

Over 400,000 people were forced to flee to El Fasher from the Zamzam refugee camp, the largest displacement encampment in Sudan just south of the city, after an RSF ground assault in April that killed more than 500 civilians.

Those who made it to the city “remained trapped, out of reach of humanitarian aid and exposed to attacks and further mass violence,” MSF said – and there is no way out.

“Survivors who managed to flee have undergone further violence along the road, with men being specifically targeted, women and girls being raped and civilian convoys attacked,” the report found. 

“The harrowing level of violence on the roads out of El Fasher and Zamzam means that many people are trapped or take life-threatening risks when fleeing. Men and boys are at high risk of killing and abduction, while women and girls are subjected to widespread sexual violence.”

The millions who successfully flee Sudan find crisis there too.The World Food Programme warned Wednesday that life-saving assistance may soon shut down in the Central African Republic, Chad, Egypt, Ethiopia, Libya, South Sudan and Uganda – all grappling with their own domestic food insecurity needs – as funding cuts and new arrivals overwhelm support systems.

“This is a full-blown regional crisis that’s playing out in countries that already have extreme levels of food insecurity and high levels of conflict,” said Shaun Hughes, WFP’s Emergency Coordinator for the Sudan Regional Crisis. “Refugees from Sudan are fleeing for their lives and yet are being met with more hunger, despair, and limited resources on the other side of the border.”

Rape as a weapon of war

Violence and attacks on healthcare forced MSF to shut down operations in El Fasher and Zamzam camp.

Sexual violence has been a central feature of the violence in Sudan throughout the war. While both the Sudanese Armed Forces and the RSF have been found to commit sexual war crimes, the overwhelming majority are attributed to the RSF and its allies.

The UN Independent fact-finding mission on Sudan and Amnesty International separately found the militia had engaged in widespread sexual and gender-based violence, rape, sexual slavery, and abduction, among other crimes against humanity. RSF forces are further accused of using mass rape as a weapon of war and to assist ethnic cleansing efforts, using rape as a tool to drive fear and force women to flee.

“I have a certificate for first aid nursing. [When they stopped us], the RSF asked me to give them my bag. When they saw the certificate inside, they told me, ‘You want to heal the Sudanese army, you want to cure the enemy!,'” one woman, 27, told MSF. “Then they burnt my certificate and they took me away to rape me.”

No comprehensive statistics on sexual violence in Sudan exist. The latest number on confirmed cases, compiled by the advocacy group Together Against Rape and Sexual Violence and published on 4 June, documented 377 cases of rape since the war began.

Data on rape and sexual assault in war zones are notoriously inexact. In Sudan, survivors face an array of barriers from social stigma, to lack of adequate medical support, and a dysfunctional judicial system with no means to protect or prosecute if they speak out. The Sudanese government’s Unit for Combating Violence Against Women previously warned verified rape cases may represent as little as 2% of the total.

Since the start of the war, the number of people at risk of gender-based violence has more than tripled to 12.1 million people – 25% of the country’s population. The number of gender-based violence survivors seeking services increased 288% in 2024, according to UN Women.

The most harrowing finding came from Unicef in May: 221 rape cases against children were recorded by since the beginning of 2024. The youngest reported survivors were four one-year-olds. Sixteen child rape survivors, including the infants, were under 5 years of age. 

“Children as young as one being raped by armed men should shock anyone to their core and compel immediate action,” said Unicef executive director Catherine Russell.

Unicef found an additional 77 instances of sexual assaults against children, mostly attempted rape cases. Two-thirds of recorded cases were girls, but 33% were boys, which the agency noted requires “specific attention as they may face stigma and unique challenges in reporting, seeking help, and accessing services.”

“Millions of children in Sudan are at risk of rape and other forms of sexual violence, which is being used as a tactic of war. This is an abhorrent violation of international law and could constitute a war crime. It must stop.”

Southern spiral

The violence consuming Sudan threatens to spill across its southern border, where South Sudan, the world’s youngest nation, stands on the brink of a new civil war of its own.

South Sudan won independence from Sudan in 2011, ending the longest civil war in the history of the African continent. Twenty-two years of violence, disease and famine killed 2 million people, the highest civilian death toll since World War II.

Independence was quickly followed by civil war. In 2013, a break-down of the power-sharing agreement negotiated two years earlier resulted in five years of war, killing 400,000 and displacing 4 million before a new power-sharing agreement brokered in 2018 brought fragile peace to the fledgling state.

That agreement collapsed once again in March when President Salva Kiir’s forces arrested his former deputy Riek Machar, mirroring Sudan’s trajectory when two rival generals, charged with overseeing the country’s transition to democracy, instead dragged the country and its 50 million people into all-out war.

Since March, violence against civilians in South Sudan has since reached its highest level since 2020, the UN reported Wednesday, with 1,607 attacks in the first quarter of this year. Those include 739 civilians killed, 679 injured, 149 abducted, and 40 subjected to conflict-related sexual violence between January and March.

The escalating violence is already pushing South Sudanese civilians towards famine. Over 22,000 people are likely already starving, while nearly 60% of the population faces life-threatening food insecurity as a result of the escalating violence, the IPC warned in June.

Armed groups move freely across the porous border drawn only in 2011, with overlapping ethnic militias and historic alliances threatening to erase the fragile line between two conflicts – trapping 61 million people, once again, in a renewed cycle of violence.

“Given this grim situation, we are left with no other conclusion, but to assess that South Sudan is teetering on the edge of a relapse into civil war,” Nicolas Haysom, the UN’s top official in South Sudan, warned when the peace deal collapsed. “It would devastate not only South Sudan but the entire region, which simply cannot afford another war.”

Image Credits: MSF, UN Sudan Envoy.

The world faces a global health funding crisis, but John-Arne Røttingen believes the solution goes beyond money. It lies in stronger partnerships between governments, researchers, and citizens.

“Science is not enough to change the world,” said Røttingen, the newly appointed CEO of Wellcome, one of the world’s largest global health foundations. “It must be allied with collaboration and action across society.”

In a wide-ranging conversation on Trailblazers with Garry Aslanyan, Røttingen spoke about his leadership values, his vision for Wellcome, and the pressing need to rethink how global health is funded and delivered. A former head of CEPI and Norway’s global health ambassador, Røttingen said foundations like Wellcome must act as catalysts—not substitutes—for government and private-sector leadership.

“We need to engage governments more directly,” he said. “Ultimately, it is governments that are responsible for the health of their populations.”

Røttingen emphasized the importance of equity in science, calling for more research led by local experts in the Global South. He described visits to research centres in Malawi, Kenya, and Vietnam, where Wellcome supports programs that combine population health with advanced laboratory science.

But trust is also key.

“We need to double down on trust in science,” he said, citing public skepticism during the COVID-19 pandemic. That includes involving communities more directly in setting research priorities.

“We have to tackle problems that are important to people,” Røttingen added.

Røttingen urged the global health community to act fast as external funding shrinks and global crises multiply.

“We have some good indications of where we should go. We just need to act on them—and bring them to life,” he said.

 

Listen to previous episodes of the Global Health Matters podcast with Dr Gary Aslanyan on Health Policy Watch.

Image Credits: Global Health Matters Podcast.

Artificial intelligence can transform global health—but only if developed and deployed with equity in mind.

That was the message from two global health experts featured on the latest Global Health Matters podcast episode, “AI for Equity: Bridging Global Health Gaps.”

“In the future, a physician working in a remote area will have the best cardiologist in the world, the best pneumologist in the world, right next to them—ready to answer any questions,” said Alexandre Chiavegatto Filho, professor of machine learning in health at the University of São Paulo.

His team is developing mobile apps that allow frontline doctors to access AI tools through smartphones, even in areas without electronic medical records.

Jiho Cha, a South Korean parliamentarian and physician, has a similar vision. He believes AI can scale up health services in fragile settings, where doctors are scarce and health systems are overwhelmed.

“AI-powered information systems combined with fintech or blockchain technologies can improve health financing and delivery,” Cha said.

He described how AI can support nurses and community health workers by enhancing diagnostic and decision-making abilities.

However, both experts warned that the same technology could widen gaps if not handled carefully.

“If you leave AI by itself, it’s probably going to increase inequality,” Filho cautioned, noting that algorithms trained on wealthier populations tend to perform worse for low-income groups.

They said the challenge is to ensure AI is trained on diverse, locally relevant data and made accessible in low-resource settings. Otherwise, the digital divide will deepen.

“We have a huge opportunity in our hands,” Filho said. “But we need to make sure AI works where it’s needed most.”

Listen to previous episodes of the Global Health Matters podcast with Dr Gary Aslanyan on Health Policy Watch.

Image Credits: Global Health Matters Podcast.

Air pollution is barely acknowledged in the draft political declaration for the upcoming fourth UN High-Level Meeting on Non-communicable Diseases (NCDs) and Mental Health. The omission of the world’s leading contributor to disease threatens global progress in tackling heart disease, respiratory diseases, stroke, cancer, and other chronic illnesses.

Since the last UN General Assembly High-Level Meeting on non-communicable diseases (NCDs) in 2018, air pollution has leapfrogged tobacco as a cause of disease and premature death worldwide.

Government representatives negotiating ahead of September’s meeting in New York City must commit to addressing this global health emergency of air pollution as the leading contributor to the global disease burden, causing more than one in ten deaths globally. 

Without clean air action, leaders will miss a golden opportunity to reduce the pressure on healthcare, improve the lives of billions of people living with NCDs, and prevent millions of cases of cardiovascular and respiratory disease, lung cancer, diabetes, mental health and neurological conditions including dementia.

In 2019, 99% of the world’s population was breathing air polluted beyond safe levels, according to WHO’s global air quality guidelines. The 2024 State of Global Air report by the Health Effects Institute shows that outdoor air pollution—driven largely by fossil fuels, transport, waste burning, and agriculture—causes 4.7 million deaths each year, while  household air pollution from cooking and heating with polluting fuels adds another 3.1 million deaths. 

That’s eight million preventable deaths every year—a staggering, unacceptable toll representing real people losing their lives to the very air they breathe.

The declaration of leaders meeting at UNGA must reflect the urgency of the issue, the life-saving potential of clean air, the cost-savings this offers to health services, and clearly call for integrated action on air pollution.

The unquestioned science

Almost everyone on earth breathes polluted air, with an impact far beyond the lungs. Fine particulate matter (PM2.5) enters the airways and is tiny enough to pass into the circulatory system and can reach nearly every organ, where it contributes to heart attacks, strokes, kidney disease, depression, anxiety, and impaired brain development in children. It also increases risks during pregnancy, including of miscarriage, stillbirth and low birth weight.

People living with NCDs are hit hardest. Air pollution causes more than a quarter of all deaths from ischaemic heart disease and stroke, almost half of all deaths from chronic obstructive pulmonary disease (COPD), and nearly a third of deaths from lung cancer, while worsening patients’ quality of life, prognosis and healthcare access. 

Countries are already off track to achieve SDG target 3.4—reducing premature NCD mortality by one-third by 2030. Most will find it impossible to meet this target without real action to reduce air pollution.

The good news is that proven, cost-effective solutions to allow us all breathe easier exist. Ministers of Health unanimously approved an updated WHO global roadmap on air pollution and health at last month’s World Health Assembly, including a target to halve mortality from anthropogenic air pollution by 2040. 

Progress towards the WHO Air Quality Guideline levels for healthy air is already underway in some regions. The European Union recently updated its Ambient Air Quality Directive, while China cut PM air pollution by more than half over the last decade, proving that clean air is compatible with rapid economic development. City mayors from every continent are showing leadership too, with 50 cities committing to stepping up clean air action earlier this year. 

Where the burden hits hardest 

Global map of national population-weighted annual average PM2.5 concentrations in 2020.

Like tobacco, alcohol and other major risk NCD factors, air pollution imposes an acutely unfair burden of disease on the lowest-income countries, and most marginalised communities. Ninety-five per cent of deaths linked to air pollution are of people in low- and middle-income countries, due to toxic pollution and under-resourced health systems. 

Despite the scale of this crisis, air pollution remains drastically underfunded. According to the State of Global Air Quality Funding 2024 report, clean air initiatives received less than 1% of international development funding between 2018 and 2022. This chronic neglect is not just a public health failure—it’s an economic catastrophe, with a toll counted in lost lives and livelihoods worldwide. 

The World Bank estimates that the cost of air pollution at US$6 trillion annually—equivalent to 5% of global GDP—from lost labour income due to illness and premature death, reduced productivity, and increased healthcare expenditures. In some of the hardest-hit countries, especially in South and South-East Asia and sub-Saharan Africa, air pollution costs exceed 10% of national GDP. 

These economic wounds stall development, entrench poverty, overwhelm fragile health systems and reveal a stark disconnect: the world is losing trillions to an entirely preventable crisis while making virtually no investment to stop it.

Fossil fuels: the overlooked driver 

An oil rig operates off the coast of Denmark.

NCD Alliance (NCDA) has voiced strong concerns over the draft political declaration, particularly the absence of any mention of fossil fuels—by far the leading driver of air pollution. Reducing fossil fuel extraction and use, phasing out subsidies, and ensuring just transition to clean energy must be central to NCD prevention efforts, but such commitments are currently absent.

NCD Alliance recommends clearly acknowledging the public health emergency posed by air pollution calls on governments to include an additional tracer target: “at least 80% of countries have adopted air quality standards to align with WHO air quality guideline level by 2030.” 

Air pollution was recognized as a major NCD risk factor by leaders at the last High-Level Meeting on NCDs in 2018, together with mental health and neurological conditions as one of the major NCD groups, creating a “5×5” framework for the NCD response. Since then, the evidence has only grown stronger on health impacts of air pollution, climate change and environmental degradation.

NCDA therefore calls for the stronger inclusion of air pollution, food systems and climate change in the text, and urges leaders to address this important nexus. Failure to do so would ignore emerging risks and lead to missed opportunities for more integrated, efficient, and forward-looking action.

Political momentum building

WHO’s Maria Neira, centre, receiving a health sector call for clean air action, presented by respiratory disease patients and paediatricians, at the WHO Air Pollution and Health Conference, March 2025.

At the 2nd WHO Global Conference on Air Pollution and Health in March 2025, governments and stakeholders endorsed a bold goal: halving the health impacts of air pollution by 2040. That target was formally approved by the 78th World Health Assembly. Achieving it would prevent three-to-four million premature deaths annually—most of them from NCDs. 

This aligns with the Sustainable Development Goals, including SDG 3.4 (reduce premature NCD mortality), SDG 3.9 (substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution), SDG 7.1 (ensure universal access to affordable, reliable and modern energy services) and SDG 11.6 (improve air quality in cities).

Leading health organizations have joined the call to action, singling out air pollution as a deadly yet underfunded and solvable crisis. The Union for International Cancer Control (UICC) has identified air pollution as a missed opportunity to improve cancer survival, noting significant differences in prognosis in more polluted countries and cities.

The World Heart Federation (WHF) has also sounded the alarm on air pollution as an under-addressed driver of cardiovascular disease, with over half of the nearly eight million annual air pollution-related deaths are due to cardiovascular conditions, according to its 2024 World Heart Report. 

WHF urges governments to adopt the 2021 WHO air quality guidelines as legally binding standards and to align clean air targets with climate and urban planning policies. Their message is clear: protecting heart health means tackling pollution at its source—especially fossil fuels—and integrating environmental, health, and economic agendas.

A test of global leadership

The General Assembly hall in the United Nations’ New York City Headquarters.

Omitting air pollution from the NCD agenda is not just an oversight—it’s a dangerous misstep. The upcoming High-Level Meeting is a unique opportunity to correct course. World leaders must explicitly commit to act on air pollution as a major NCD risk factor in their political declaration. 

This should include developing national air quality standards that align with WHO guidelines, curbing emissions from key sources, and evaluating the cost savings from cleaner air to inform health system planning and budgets. Governments and donors must step up with stronger investments in clean air, especially for the most affected communities.

Clean air is not a luxury—it is a human right, especially for people living with NCDs. 

Leaders have the power to reverse this public health failure and economic disaster while delivering clear public health policy success: hospital admissions falling within days and weeks, healthier babies born in the ensuing months, and NCD trends continuing to improve over decades.

The science is beyond doubt, the solutions are proven, and Ministers of Health and Environment have committed on the international stage. The world now needs leaders to recognize the urgency of this crisis and seize this opportunity to save both lives and money. Including air pollution in the NCD agenda is not optional—it is vital.

About the authors

Alison Cox is the Policy, Advocacy and Accountability Director of the NCD Alliance, a global network of civil society organisations dedicated to transforming the fight against noncommunicable diseases.

Nina Renshaw is a career-long advocate for clean air, joining Clean Air Fund as Head of Health in 2022. She has twenty years of experience of international policy and advocacy in diverse fields, including health, environment, economy, transport and international development.

Image Credits: Giorgia Galletoni , CC, Patrick Gruban.

USAID closes days after leading medical journal warned of millions of deaths per year from a halt to operations.

US Secretary of State Marco Rubio announced the official end of USAID, eliminating the world’s largest humanitarian aid agency just days after a landmark study warned the closure would cause 2.4 million preventable deaths every year.

The study published 30 June in The Lancet found USAID-supported programs saved 92 million lives in low- and middle-income countries over the past two decades, including 30.4 million children under the age of five. Without this support, researchers project 14 million additional premature deaths by 2030 – as a result of the closure of the agency founded in 1961.

“Unless the abrupt funding cuts announced and implemented in the first half of 2025 are reversed, a staggering number of avoidable deaths could occur by 2030,” warned the 15 authors of the study, led by  researchers at Barcelona’s ISGlobal and five other Spanish institutes, the Institute of Collective Health in Brazil, the Centro de Investigação em Saúde de Manhiça, Mozambique, and the University of California, Los Angeles.

Rubio has ignored such warnings.

In a State Department memo titled “Make Foreign Aid Great Again” announcing the shutdown, Rubio laid into USAID, stating its “charity-based” model was against American interests and that it spawned “a globe-spanning NGO industrial complex at taxpayer expense.” He also attacked recipient countries and regions – notably Sub-Saharan Africa – for not repaying the US with UN votes despite billions in aid.

The move marks the final chapter in the rapid dismantling of the agency since January, upon which millions of the world’s most vulnerable people relied upon for vital health, nutrition and other development assistance. That saga began in January, when Elon Musk, the world’s richest man, famously tweeted he had skipped “some great parties” to put USAID “into the wood chipper,” telling the agency: “Time to die.”

The Trump administration had previously cancelled 83% of its aid operations earlier this year, throwing the international aid world into chaos. What remains of old US AID programmes will be “targeted and limited,” and be folded into the State Department, the memo said.

“USAID viewed its constituency as the United Nations, multinational NGOs, and the broader global community—not the U.S. taxpayers who funded its budget or the President they elected to represent their interests on the world stage,” Rubio wrote, adding that the agency “has little to show since the end of the Cold War.”

‘No one has died’

US Secretary of State Marco Rubio told Congress no one is dying from tens of billions in cuts to foreign aid.

Rubio’s State Department letter makes no mention of humanitarian concerns, instead reflecting the transactional view that has underpinned the Trump administration’s trade policy and America First foreign policy approach.

As for the estimates mortality projections tabled by scientists,  the architects of USAID’s dismantling tell a different story: no one is, has or will die.

“No one has died because of USAID [cuts,]” Rubio told Congress in late May, months after the majority of its operations were already terminated. “No children are dying on my watch.”

Musk echoed the same sentiment in March: “No one has died as a result of a brief pause to do a sanity check on foreign aid funding. No one.”

Fact Check

The stories at country level say something very different.

In Sudan, a mother described watching her toddler die from a treatable chest infection after the termination of antibiotic supplies to local clinics following the USAID cuts.  Others watched their babies starve while older children died begging for food, after soup kitchens were closed, according to one field report  by the Washington Post. And the absence of US-funded disease response teams has made it harder to contain deadly cholera outbreaks, doctors reported.

In East Africa countries like Zimbabwe, where USAID has long provided HIV medication, the sudden cuts left thousands without access to life-saving antiretroviral drugs, according to another report, by Health Policy Watch.  See related story.

Bribes and Rationing of AIDS Medicine in Zimbabwe as Trump’s Aid Cuts Bite

Thousands of organizations running health clinics, vaccination centres, food distribution sites, water purification drives, and other life-saving activities will be forced to curtail activities or shut down altogether, cutting off basic services.

In 2023 alone, USAID provided essential healthcare to 92 million women and children, as well as services to 20 million people infected with HIV. Many of those services now gone or in suspension until Congress decides if it will extend the lifespan of the President’s Emergency Program on AIDS Relief (PEPFAR), whose latest one-year authorization expired in March.

International aid organizations, including UN agencies and major charities, are struggling to cope with the loss of more than $60 billion in US funding. Facing steep staff cuts and slashed budgets, none are positioned to quickly replace USAID’s operations or maintain the same reach to vulnerable populations.

USAID’s Health Legacy

Elon Musk, who was named a “special government employee” by the Trump administration, secured the president’s backing to eliminate USAID, the country’s foreign aid agency, sending shockwaves through global humanitarian efforts.

That “sanity check” on foreign aid has since morphed into a total halt. This is particularly dramatic in the health sector, where the US has been the backbone of aid – totalling nearly a third of all health aid globally – for decades as the Lancet illuminates what will be lost.

The Lancet analysis found that higher levels of USAID funding—primarily directed toward low and middle-income countries, particularly in Africa—were associated with a 15% reduction in all-cause mortality and a 32% reduction in deaths of children under five.

The agency’s programs achieved remarkable reductions across multiple disease categories: a 65% reduction in HIV/AIDS deaths (saving 25.5 million lives), 51% reduction in malaria deaths (8 million lives), and 50% reduction in deaths from neglected tropical diseases (8.9 million lives).

Among the programs affected by the cuts is the President’s Emergency Plan for AIDS Relief (PEPFAR), which has saved an estimated 26 million lives through HIV treatment and prevention. Its collapse would have immediate, devastating consequences: in just three months, nearly 136,000 babies – about 1,500 each day – would be born with HIV as pregnant women lose access to transmission-prevention medication.

Significant decreases were also observed in mortality from tuberculosis, nutritional deficiencies, diarrheal diseases, lower respiratory infections, and maternal and perinatal conditions.

“Is [USAID] a good use of resources? We found that the average taxpayer has contributed about 18 cents per day to USAID,” James Macinko, a health policy researcher at UCLA and study co-author told NPR. “For that small amount, we’ve been able to translate that into saving up to 90 million deaths around the world.”

Charity is bad

Low-income countries on average depend on foreign aid for one-third of their national health spending. Eight of the world’s poorest countries—South Sudan, Somalia, Democratic Republic of Congo, Liberia, Afghanistan, Sudan, Uganda and Ethiopia—rely on USAID for over 20% of their total foreign assistance.

Facing their highest debt burdens in decades, many of the world’s poorest nations are unlikely to be able to compensate for the budget hole blown open by USAID’s withdrawal.

Former President Barack Obama called the decision to dismantle USAID a “colossal mistake,” saying the agency’s efforts to prevent disease, fight drought and build schools made it synonymous with America itself. “To many people around the world, USAID is the United States,” Obama said.

Citing two anecdotes – a Zambian man who told American diplomats teaching his countrymen to “learn to fish” instead of receiving US aid, and an Ethiopian woman praising two-way investment schemes – Rubio said the new model will provide “targeted and limited” aid, while favoring nations who demonstrate an “ability and willingness to help themselves” and welcome US investment.

“The charity-based model failed because the leadership of these developing nations developed an addiction,” Rubio said. “That ends today, and where there was once a rainbow of unidentifiable logos on life-saving aid, there will now be one recognizable symbol: the American flag.”

The United States flag has for decades been on the center of all aid packages distributed by the agency.

Image Credits: White House .

The World Health Organization flag flies above its headquarters in Geneva.

World Health Organization Director General Dr Tedros Adhanom Ghebreyesus announced his new team of 36 directors at headquarters on Tuesday, according to an internal message to WHO staff, seen by Health Policy Watch.

Nine of the appointments, including key positions heading the Departments of Noncommunicable Diseases and Mental Health, and the newly-combined Department of Environment, Urban Health, Climate, Migration, and One Health, are “acting” with permanent appointees to be named at some point in the future, according to the message. 

The appointment of the directors completes the latest phase of WHO’s reorganisation following a budget crisis triggered by the withdrawal of the United States, WHO’s biggest donor, in January 2025, and its abrogation of dues payments, even for the 2024 year. 

In the wake of the US exit, WHO member states slashed WHO’s projected 2026-27 base budget by over 20%, yet it remains about $1.65 billion underfunded. In May, World Health Assembly members also agreed to a 20% increase in assessed fees for member states, handing a lifeline to WHO’s operations. Still, WHO is faced with a need to reduce overall staff costs by 20-25%. 

In May, Tedros slashed the number of major WHO programme divisions from 10 to just four, announcing a pared-down senior leadership team of six Assistant Director Generals, as compared to 11 previously.  Tedros also promised to reduce the number of costly D1 and D2 directors in WHO’s headquarters from over 76 to just 34, as the next step in the massive restructuring.

In fact 36 directors were named today, and the fate of other directors not named for positions at headquarters remains to be seen. As most directors hold long-term contracts, it’s likely the organisation will try to match them to positions elsewhere in regions, as contract termination costs would also represent a heavy expense.

The sweeping leadership cuts at WHO follow months of upheaval across UN agencies as organizations from UNHCR to OCHA that cut similar shares of staff to adapt to the first US withdrawal from their operations since the UN’s founding in 1945 – a loss of billions of critical dollars across Geneva.

New WHO organizational plan, announced on 22 April, reduces 10 divisions at headquarters to just four.

Health Promotion, Disease Prevention and Control

Top amongst the familiar names in the big new division of Health Promotion, Disease Prevention and Control, headed by Jeremy Farrar, are: Katherine O’Brien, as director of Immunization, Vaccines and Biologicals;  Luz Maria De Regil, as director of Nutrition and Food Safety previously the unit chief for Multisectoral Action in Food Systems; and Etienne Krug, longtime director of the Department of Health Promotion, Social Determinants and a politically powerful WHO actor with strong connections to donors.

Tereza Kasaeva, former head of WHO’s TB department, has been named director of the newly combined WHO Department of HIV, Tuberculosis, Hepatitis, and Sexually Transmitted Infections. 

Meg Doherty, who formerly headed the HIV Department, has meanwhile, been named as director of the department of Science, Research, Evidence and Quality for Health, under the new Chief Scientist, Dr Sylvie Briand. 

Tereza Kaseva in her previous role as TB department chief.

The twin appointments of Kasaeva, a Russian national,  to the new HIV/TB Department and Doherty, an American, to the department under the Chief Scientist’s office represent a kind of Solomonic choice for Tedros, observers said.  Despite the US abrogation of its engagement with WHO, Tedros has been careful about ruffling geopolitical feathers on either side of the Atlantic.   

Meanwhile, Pascale Allotey has been named director of two major departments that remain distinct in name, at least for now. Those include the new WHO Department of Maternal, Newborn, Adolescent and Child Health; Healthy Ageing, and Sexual and Reproductive Health, a merger of three former teams. Allotey is also slated to lead the Human Reproduction Programme, a WHO-hosted joint initiative with the UN Development Programme (UNDP), the UN Population Fund (UNFPA) and UNICEF, the UN Children’s Fund.

WHO Organization, as of January 2025, boasted 10 divisions and nearly 60 departments.

Health Systems

Dr Yukiko Nakatani (middle), heads Health Systems, one of three major programme divisions in the new WHO reorganization.

In terms of the second of three big new programme divisions, Health Systems, headed by Yukiko Nakatani, Rogerio Gaspar, a well-respected Portuguese researcher, has remained as director, Prequalification and Regulation of Medicines and Health Products – a critical WHO department that evaluates new medicines, vaccines, and medical devices. 

WHO’s “prequalification” seal of approval is regarded as a greenlight for bulk procurement by UNICEF, the Global Fund, and Gavi, The Vaccine Alliance, as well as for national ministries of health that lack capacity to do independent evaluations themselves.   

Similarly, Deusdedit Mubangizi is remaining as director, Policy and Standards for Medicines and Health Products, which works hand in hand to develop WHO’s Essential Medicines List decision. Notably a new EML on weight loss drugs and drugs for rare diseases is supposed to be forthcoming soon. 

In other key appointments to that division: Alain Bernard Labrique, a former professor at Johns Hopkins and WHO Director of Digital Health, is now the director of Data and Analytics, Digital Health, and Delivery for Impact; Dr Yvan Hutin is now director of  Antimicrobial Resistance; while Kalypso Chalkidou, who has led WHO’s Department of Health Financing and Economics since last year, was named as director of the newly-combined WHO Department of Governance, Financing, Economics, Primary Healthcare, Universal Health Coverage.  

Health Emergencies Preparedness and Response 

In the third new programme division of Health Emergencies Preparedness and Response, where Chikwe Ihekweazu has replaced the retiring Executive Director Mike Ryan is being replaced by, five department directors have been named.

Those named include: Altaf Sadrudin Musani, as director of Humanitarian and Disaster Management; Nedret Emiroglu, a long-time WHO European office figure as director of Pandemic and Epidemic Management; Stella Chungong, former director of Health Security Preparedness, now morphed into the Department of Health Emergency Preparedness. 

WHO ADG of Health Emergencies, Chikwe Ihekweazu (far right).

In terms of their public-facing profiles, they are largely unknown quantities, observers say. 

Other appointments include Oliver Morgan as director of WHO’s Health Emergency Intelligence and Surveillance, replacing Ihekweazu at the helm of the Berlin-based hub; and Abdirahman Sheikh Mahamud as head of the department of  Health Emergency Alert and Response Operations.

Notably, Maria Van Kerkhove, who was one of the most familiar faces of WHO during the COVID pandemic, and has remained the go-to expert on the virus in recent press briefings at WHO headquarters, was not named to a position in the Emergencies Division.

Director General’s Office 

In the Director General’s Office, Dr Jamal Abdirahman Ahmed is continuing as director of Polio Eradication following his appointment to the role in March.  

Derek Walton will remain in his role as chief legal counsel for the agency. Gaudenz Silberschmidt remains director, Partnerships, Resource Mobilization, Envoy for Multilateral Affairs. And Alia El-Yassir continues as director of Gender Equality, Human Rights, Health Equity, and Prevention of and Response to Sexual Exploitation and Abuse.

The WHO’s organizational restructuring accompanies a growing financial crisis at the agency, which faces a $1.65 billion budget shortfall for 2026-27 despite extensive fundraising efforts.

Unfilled and acting posts 

The nine key positions which remain officially vacant, and for which only acting directors have been named, include key strategic departments such as Noncommunicable Diseases and Mental Health (Devora Kestel) and the Department of Environment, Urban Health, Climate, Migration, and One Health, where Rüdiger Krech is taking over from WHO’s Maria Neira, the iconic face of WHO’s climate and environment work, who is retiring.  As per Tedros’ announcement, the old department of Health and Migration also appears to have also been grafted into that new mega-Department since the initial WHO organigram was published in May.

In the key post of WHO Director of Communications, Gaya Gamhewage, previously director of the Prevention & Response to Sexual Misconduct, will serve as acting director, taking over from Gabriella Stern, who is also retiring. 

Within the Division of Health Systems, the Director’s post for the Global Centre for Traditional Medicine will remain vacant, with Shyama Kuruvilla acting.

As for the new department of the WHO Academy, Health Workforce and Nursing – a merger of three former entities – the acting director is David Atchoarena, who was appointed in 2023 to head the WHO Academy, a flagship project of Tedros, following a long career at the UN Educational, Scientific and Cultural Organization, UNESCO. 

Dr. Gaya Gamhewage, Director, Prevention & Response to Sexual Exploitation, Abuse and Harassment, World Health Organization, speaks on 29 November, 2022 at the United Nations in Geneva.

The directorship of Malaria and Neglected Tropical Diseases also remains vacant, with Daniel Ngamije Madandi as acting.

In addition, the directorship of TDR, the Special Programme for Research and Training in Tropical Diseases, also remains vacant following the retirement just last month of John Reeder, an Australian national.  

With respect to TDR, another WHO-hosted programme, there has also been talk of appointing a director of a related WHO department as dual director for TDR – rather than making another distinct and costly appointment. 

Continuity or complicity? A leadership dilemma

Dr Mike Ryan, director of the World Health Organization’s emergency response division, held his final press conference Friday in Geneva after eight years leading the UN health agency’s response to global health crises.

While the new appointments mark an important step in WHO’s structural reform, they also underscore a deeper tension: how much continuity is too much?

Many of the individuals retained or reappointed to leadership positions are well-tested and respected professionals in their fields. Others, while familiar, are also emblematic of an entrenched culture that critics argue is ill-equipped for WHO’s current crisis.

But others arrived at WHO, not as a result of truly open global searches, but rather via internal handpicking — a trend that has accelerated under the current Director-General, eroding transparency and weakening trust in WHO’s merit-based system.

Some, like Dr Tereza Kasaeva, reportedly arrived with overt political backing (in her case, Russian authorities at the time of Dr Tedros’s first election), raising longstanding concerns about geopolitics shaping technical leadership.

Invisible retention and the illusion of reform

WHO Director-General Dr Tedros Adhanom Ghebreyesus and Raul Thomas, the Assistant Director-General for Business Operations at WHO address the committee following the successful vote on the agency’s new budget.

Despite the rhetoric of bold reform and downsizing, critics fear that many senior staff not formally reappointed may still be quietly retained within WHO’s financial system — undermining the promise of a leaner, more accountable leadership.

According to reports from staff with access to WHO’s Global Management System (GSM), the Canadian physician Bruce Aylward, formerly Assistant Director General for Universal Health Coverage and Life Course, so far remains listed on the WHO payroll records as a D2-level official until his retirement in 2027 –  even after being left out of the new six-member WHO senior leadership team, announced by Tedros in May.

Similarly, Santino Severoni, former director of Health and Migration, reportedly continues to be listed in WHO’s GSM records as a D1 director until 2029, despite the fact that he has not been named to any department so far.

These arrangements raise difficult questions about whether WHO is truly cutting fat or simply relocating it.

Meanwhile, others like Krech, who previously directed WHO’s Department of Health Promotion, was made the acting director of the newly merged Department of Environment, Urban Health, Climate, Migration, and One Health, despite a lack of intimate familiarity with that arena. 

“We hope there will be an open advertisement,” commented one source. 

Financial governance itself is now overseen in part by Sushil Rathi (acting director of finance), a figure whose own entry into WHO came via a process tied to the now-defunct Indian firm Satyam — the same company that originally built WHO’s Global Management System (GSM).

The hidden costs of keeping the old guard

WHO's New Leadership Team
World Health Organization headquarters in Geneva.

Financially, retaining internal appointees is the easier path. It avoids large indemnity payouts for terminated contracts and offers a surface-level appearance of continuity. But the cost of clinging to underperforming or politically tainted leaders may be far greater in the long run — eroding staff morale, weakening donor trust, and compromising the boldness needed for WHO to truly reinvent itself.

“We are caught in a trap. Either we recycle leaders who helped create this mess, or we bring in outsiders with no real grasp of WHO’s dysfunction,” said one senior staffer privately.

Without a robust, meritocratic and depoliticized process to identify the next generation of WHO leadership, the reforms risk being cosmetic — changing the structure while leaving the culture untouched.

Image Credits: US Mission in Geneva / Eric Bridiers via Flickr, WHO, WHO, 2025, Japan MoH, Edith Magak, Israel in Geneva/ Nathan Chicheportiche, Guilhem Vellut.

Dr Mike Ryan steps down after a near three decade career at WHO.

Dr Mike Ryan, director of the World Health Organization’s emergency response division, held his final press conference Friday in Geneva after eight years leading the UN health agency’s response to global health crises from war and famine to disease outbreaks.

In his farewell remarks, Ryan warned of an “era of collapsed funding” following the Trump administration’s decision to halt funding for UN agencies and international humanitarian efforts while withdrawing from WHO for a second time, compounding a global trend of declining humanitarian and health aid that has dropped a bomb on Geneva’s humanitarian sector.

“It’s easy to be brave when there’s nothing at stake. It’s hard to be courageous when everything’s at stake and I think we live in a world where a lot is at stake,” Ryan said. “Immunization is at stake, peace is at stake, health is at stake. Honesty is at stake. Truth is at stake. So I think we have a common cause.”

Ryan, an Irish epidemiologist who has led WHO’s Health Emergencies Programme since 2017, has been at the forefront of the organization’s response to humanitarian crises from Gaza to Myanmar and Sudan, as well as Ebola outbreaks and other disease emergencies across the globe. He became particularly visible during the COVID-19 pandemic, where his direct, plain-speaking style made him one of WHO’s most recognizable faces.

His farewell coincided with WHO’s release of the latest report from its Scientific Advisory Group for the Origins of Novel Pathogens (SAGO), which concluded that China continues to withhold data necessary to determine how COVID-19 emerged, leading Ryan to address the controversy and call for international cooperation despite ongoing conflicts.

“Would I like to know what the origins of this virus are? Yes, because we want to be able to shut the door, close the trap door, so that virus can never escape again, but there are many, many other viruses in the world,” he said.

“We need to continue to look at origins and everything else, but if that’s only been driven by political outcomes, if that’s only been driven by the intent to hurt, if your intent to investigate is only to punish, you will never have justice,” Ryan continued. “If your intent to investigate is to be enlightened, then you will find justice through the process.”

Ryan, who joined WHO in 1996, is one of the organization’s longest-serving senior officials. His field experience included coordinating responses to cholera, meningitis, and hemorrhagic fever outbreaks across Africa, Asia and the Middle East, often in areas affected by conflict and displacement.

Ryan defended the progress made during his tenure in global health cooperation through improvements in the International Health Regulations, pandemic accord negotiations, and institutions like Gavi and the pandemic fund.

“We’ve moved progressively in cooperation in the IHR revision of 2005 and into the IHR amendments provision under Tedros, the pandemic accord,” Ryan said. “We’re actually learning better ways to cooperate globally on epidemics and on emergencies.”

“Are we getting better at this? We are,” he added. “Are we perfect? No, we’re not.”

His acknowledgment of the imperfections of WHO, its sister UN agencies, and international aid organizations came with a plea for continued support, noting the complexity of their global mandates amid shrinking resources.

“In this era of collapsed funding, of mistrust in public institutions, of the attacks that international UN and NGO organizations are under, this is not helping,” Ryan said.

Ryan’s departure comes as WHO faces an existential funding crisis that has forced it to trim its ambitions across the world. The US funding cuts have transformed Geneva’s already underfunded humanitarian system, but Ryan argued that withdrawing support would only worsen global health security.

“One needs to be courageous at times like this,” he said. “Our job is to enlighten you as to what the real issues are. We have a framework that’s been approved by our member states. That’s enough to move forward.”

Dr Marietjie Venter, SAGO chair and Professor, University of Witwatersrand, South Africa

A four year WHO-sponsored investigation of the origins of the COVID pandemic by an international group of experts has concluded that “most scientific data and accessible published scientific evidence” support the hypothesis that the novel SARS-CoV2 virus first entered the human population either directly from virus-carrying bats, or from bats to humans via intermediate hosts.  

But the possibility that the virus escaped from a lab leak remains on the table, the Scientific Advisory Group for the Origins of of Novel Pathogens (SAGO) said in a press conference just ahead of the publication of its final report on Friday.

Large gaps in data provided by China, as well as a lack of access to key United States and German intelligence reports, have confounded investigation of the lab leak hypothesis, the 27-member report of international experts concluded.  

“ Much of the information needed to assess this hypothesis has not been made available to WHO and SAGO, despite repeated request to the government of China, and therefore this hypothesis could not be investigated or excluded,” said Dr Marietjie Venter, SAGO chair and Distinguished Professor at the University of the Witwatersrand, South Africa. 

“Data provided in intelligence reports was also assessed, but tended to be very speculative, based on political opinions and not backed up by science,” Venter added. 

“SAGO and WHO have requested further information from member states, including the government of China, Germany and the United States of America, on an unpublished [intelligence] report that has been reported in the press. However, at the time of writing the required information, has not been provided to WHO or SAGO.” 

Maria Van Kerkhove: Work on the origins of the COVID pandemic is ‘unfinished.’

“The work to understand the origins of COVID-19 is unfinished,” said Maria Van Kerkhove, WHO’s technical lead during most of the pandemic. “We really need official and further information from China, because this is where the first cases were reported.

“This is a global search, but it really is important to make sure that the comprehensive studies that need to be done in China, where those first cases were reported, are conducted. More work needs to be done,” she said.

Zoonotic transmission via the Wuhan live animal market or another source?

Caged animals held for sale and slaughter in unsanitary conditions at Wuhan’s Huanan Seafood Market, prior to the outbreak of COVID-19, including: (a) King rat snake (Elaphe carinata), (b) Chinese bamboo rat (Rhizomys sinensis), (c) Amur hedgehog (Erinaceus amurensis) (the finger points to a tick), (d) Raccoon dog (Nyctereutes procyonoides), (e) Marmot (Marmota himalayana) (beneath the marmots is a cage containing hedgehogs), and (f) Hog badger (Arctonyx albogularis).

In terms of the most plausible hypothesis, questions also remain as to whether SARS-CoV2 first infected humans via animals in the Wuhan live animal market, or whether the market simply became an efficient site for the virus transmission after an infected human worked or visited there.

“SAGO is not currently able to conclude exactly when, where, and how SARS-CoV2 first entered the human population,” she explained, adding that “the closest known precursor strains were identified in bats in China in 2013 and in Laos in 2020.

“These strains are too distantly related to SARS-CoV2 to be the direct source of the COVID-19 pandemic,” Van Kerkhove said. “The Huanan seafood market in Wuhan, China, played a significant role in the early transmission and amplification of the virus, with 60% of early cases in December 2019 that could be traced to the market or [people who] lived in close proximity to the market with a risk of exposure to visitors or animal products from the market. No evidence exists of widespread human or animal cases prior to December, 2019, anywhere.” 

And at the same time, there are in fact two SARS-CoV2 lineages, which were identified in infected humans at the market. This suggests that there had already been prior evolution in animals or in humans, rather than a single source, she said.

“Metagenomic evidence identified several species of wildlife that were present in the market that can be considered as potential intermediate hosts and that might have infected early human cases. Comprehensive upstream investigation at the source of wildlife species trade at this market and other markets in and around Wuhan is, however, still lacking. It is therefore not yet clear if the seafood market was where the virus first spilled over into humans or if it occurred through upstream-infected humans or animals at the market.” 

As per those questions, China has shared some of this information, “but not everything that we have requested,” Venter said.  “China has provided hundreds of viral sequences from individuals with COVID-19 early in the pandemic, but more detailed information [is needed] on animals sold at markets in Wuhan, and information on work done and biosafety conditions at laboratories in Wuhan. 

Looked at four hypotheses 

The committee examined four hypotheses, including: a spillover from animals to humans, via bats or indirectly; an accidental lab leak during field investigations or due to a break in biosafety; a third hypothesis, promoted by the Chinese in the early days, that the virus was transmitted via imported frozen food products imported into China;  and a fourth hypothesis, promoted by conspiracy fans, that the virus was the product of deliberate laboratory manipulation.

The third hypothesis was ruled out, SAGO concluded, and the fourth, regarding deliberate manipulation, remains “largely unsupported by other scientific and intelligence reports,” Venter added.

SAGO will reevaluate these hypotheses, should additional scientific evidence become available. In the meantime, a zoonotic origin, with the spillover from animals to humans, is currently considered the best supported hypothesis by the available scientific data, until further requests for information are met,” she said, adding: “Until more scientific data becomes available, the origins of SARS CoV2, and how it entered the human population will remain inconclusive.” 

Image Credits: Trinity Care Foundation/Flickr, Nature .